The Denial Management Analyst manages disputed or denied claims by analyzing medical records and payer policies to recover reimbursements in a hospital setting. Reviews and responds to payer audits. Ensures accurate ICD-10 coding, analyzes denial and audit trends to identify root causes, and coordinates appeals through documentation, contract reviews, and payer negotiations. The analyst supports process improvements, tracks appeals, and collaborates with clinical and revenue teams to efficiently review and resolve claim denials. Follows payer-specific rules, federal and state regulations, and industry trends under limited supervision.

• Highly detail-oriented with advanced organizational and prioritization skills, capable of managing complex and high-priority projects concurrently.
• Expert proficiency in Microsoft Word, Excel, PowerPoint, and Outlook
• Exceptional verbal and written communication skills, including drafting high-level memorandums, letters, and official correspondence.
• Expert knowledge of hospital billing, appeals processes, and denial management, with the ability to handle complex payer disputes, escalated claims and audits.
• In-depth understanding of payer contracts, Medicare/Medicaid guidelines, and audit requirements.
• Strong familiarity with industry best practices in revenue cycle management.
• Proficient in navigating office software, billing systems, and abstracting tools, with demonstrated expertise in using coding resources.
• Advanced understanding of insurance authorizations, benefits, coverage, and eligibility as they relate to medical billing.
• Expertise in reimbursement practices and payer-specific requirements, ensuring compliance and optimal reimbursement.
• Ability to mentor and guide Tier 1 and Tier 2 billers in billing processes and denial resolutions.
• Expertise in conducting root cause analysis and providing solutions to recurring billing issues.
• Stay current on payer-specific guidelines, industry trends, and regulatory requirements to ensure compliance and billing efficiency.

Education:

• Associate's degree in a related field required

• Review Denied Claims: Analyze denied insurance claims to determine the root cause of denials and identify corrective actions.
• Respond to Payer Audits: Prepare and submit required documentation, including medical records, for payer-requested audits and prepayment reviews.
• Appeal Denials: Develop and submit appeals using medical records, appeal letters, and other supporting documentation to recover denied revenue.
• Trend Analysis: Analyze denial and audit trends to identify patterns and recommend process improvements to reduce future denials.
• Verify Coding Accuracy: Work with corresponding departments to ensure proper ICD-10, CPT, and HCPCS codes are applied in the electronic medical record (EMR) and billing systems.
• Contract Review: Review managed care contracts to verify the appropriate application of reimbursement rates, provisions, and terms.
• Negotiate Resolutions: Communicate with payers to resolve technical denials and ensure compliance with contract provisions and guidelines.
• Track Appeals and Outcomes: Maintain detailed records of appeals, their statuses, and outcomes to ensure timely resolution and accurate reporting.
• Support Process Improvement: Collaborate with clinical denial management and revenue integrity teams to implement strategies that minimize claim denials.
• Educate Staff: Act as a resource for team members on denial reasons, payer-specific policies, and the appeals process, escalating issues when necessary.
• Stakeholder Collaboration: act as a liaison between internal departments and external parties (e.g., payers, auditors) to address claim and audit issues.
• Ensure all work is performed with strict confidentiality while adhering to production and quality goals.
• Handle high-level appeals, including preparing documentation and negotiating outcomes with insurance companies.
• Manage escalated claims with significant financial impact, such as underpayments or disputed claims.
• Conduct root cause analysis on recurring denial issues and recommend solutions.
• Perform all other duties as assigned by supervisor or manager.